Coronavirus in South Asia: Is low testing hiding scale of the outbreak?

Woman in Pakistan wearing facemask Image copyright Getty Images
Image caption Cases in Pakistan are on a downward trend

India has the third largest number of coronavirus cases in the world after the US and Brazil with 1.4 million infections reported so far.

That's not surprising given its huge population, but what is the scale of the epidemic in neighbouring countries?

Is the outbreak growing in South Asia?

With cases doubling every 21 days, India's numbers are rising fast after it relaxed a strict lockdown, imposed in the last week of March.

India has been seeing record numbers of daily cases, as it continues to ramp up its testing, currently conducting over 500,000 tests each day.

However, other countries in South Asia seem to be on a different trajectory, with confirmed infections showing a downward trend, after steep increases in May and June.

In Pakistan, with the second-highest number of total cases in the region, there is cautious optimism after cases fell from a peak in mid-June of almost 6,000 new infections each day, to less than 2,000 by mid-July.

However, the government has voiced concern about citizens not wearing masks and observing social distancing, especially with the Eid holiday coming up.

And Bangladesh, which had a total of 223,453 cases as of 27 July, saw its daily cases peak between mid-June and the beginning of July, and has since also seen a downward curve.

Afghanistan's rate of increase is slower than its neighbours', although there are questions about the reliability of its official figures.

Nepal and Sri Lanka have much lower levels of infection.

In Nepal, the government imposed a lockdown which went on for 100 days, during which time most cases were in areas bordering India. It's imposed new restrictions in several provinces owing to a rise in infections.

Sri Lanka has had spikes in cases since April, but has managed to keep the numbers low. It has implemented a tight lockdown, traced contacts of positive patients and imposed strict quarantine rules.

Image copyright Getty Images
Image caption Sri Lanka imposed tough restrictions on movement across the island

"A thorough contact-tracing system was in place using public health officers, local police, intelligence officials and local administrative officials," says BBC Sinhala's Saroj Pathirana.

Sri Lanka has recently lifted the lockdown ahead of forthcoming parliamentary elections.

How much testing is done in South Asia?

South Asia has about a quarter of the world population, but only 12% of total recorded infections are from this region.

"Total number of cases per million in India and the rest of South Asia are low, but so is the number of tests per million," says virologist Dr Shahid Jameel.

He says that while total numbers of tests in these countries seem high, they are not when you factor in population size.

India has has so far conducted 10.7 million tests. Pakistan has carried out more than 1.9 million.

But per capita tests in these countries are far lower than in other countries.

And in Pakistan and Bangladesh, testing levels have fallen, which will have had an impact on the number of positive cases recorded.

Pakistan, at its peak, conducted over 31,000 tests per day, but this has been scaled down since the last week of June, and they are not testing those without symptoms.

A recent government survey conducted in and around the Pakistani capital, Islamabad, suggested that nearly 300,000 people may have been infected by the virus there alone, a majority of them asymptomatic.

Bangladesh's testing numbers have also gone down after the government introduced a high testing fee. There's also been a scandal around the sale of fake negative test certificates.

In Nepal, a total of 335,000 tests had been conducted as of 26 July. The government had said earlier that they would conduct 10,000 tests per day from July, but testing remains low, at around 4,000 a day.

Testing data for Afghanistan is not available and the Red Crescent has expressed concern that the actual number of cases could be much higher than officially announced.

The World Health Organization (WHO) has set a benchmark range for adequate testing of between 10 and 30 per confirmed case in a country or region.

South Asian countries fare poorly on this measure.

Russia and Japan, which have populations similar to Bangladesh, are testing far more widely, finding a positive case every 34 and 24 tests respectively. But Bangladesh is identifying one positive case for every five tests carried out, which is well below the WHO benchmark.

Nepal was finding a positive case for every 18 tests until July 24, down from 25 tests as of June 14.

What about the death rate in South Asia?

Deaths recorded in these countries are far lower than in western countries, whether we look at absolute numbers or per head of population.

data in detail

Scroll table to see more data

*Deaths per 100,000 people

US 147,843 45.2 4,278,626
Brazil 87,618 41.8 2,442,375
UK 45,759 68.2 300,111
Mexico 44,022 34.9 395,489
Italy 35,112 57.9 246,286
India 33,408 2.5 1,480,073
France 30,209 46.5 183,079
Spain 28,432 60.9 272,421
Peru 18,418 57.6 389,717
Iran 15,912 19.5 293,606
Russia 13,483 9.3 822,060
Belgium 9,822 85.5 66,428
Chile 9,187 49.1 347,923
Germany 9,127 11.0 207,382
Canada 8,945 24.1 116,471
Colombia 8,777 17.7 257,101
South Africa 7,067 12.2 452,529
Netherlands 6,141 36.0 53,162
Pakistan 5,865 2.8 275,225
Sweden 5,700 57.2 79,395
Turkey 5,630 6.8 227,019
Ecuador 5,532 32.4 81,161
Indonesia 4,838 1.8 100,303
China 4,656 0.3 86,783
Egypt 4,652 4.7 92,482
Iraq 4,458 11.6 112,585
Argentina 3,059 6.9 167,416
Bangladesh 2,965 1.8 226,225
Saudi Arabia 2,760 8.2 268,934
Bolivia 2,647 23.3 71,181
Romania 2,206 11.3 45,902
Switzerland 1,978 23.2 34,477
Philippines 1,945 1.8 82,040
Ireland 1,764 36.6 25,892
Guatemala 1,761 10.2 45,309
Portugal 1,719 16.8 50,299
Poland 1,676 4.4 43,402
Ukraine 1,650 3.7 68,030
Kyrgyzstan 1,329 21.1 33,718
Panama 1,322 31.7 61,442
Afghanistan 1,270 3.4 36,368
Honduras 1,166 12.2 39,741
Algeria 1,163 2.8 27,973
Dominican Republic 1,083 10.2 64,156
Japan 998 0.8 31,586
Nigeria 860 0.4 41,180
Moldova 748 18.5 23,154
Sudan 720 1.7 11,424
Armenia 719 24.4 37,629
Austria 713 8.0 20,558
Denmark 613 10.7 13,547
Hungary 596 6.1 4,456
Kazakhstan 585 3.2 84,648
Serbia 543 7.8 24,141
Belarus 538 5.7 67,251
Yemen 483 1.7 1,691
Israel 474 5.7 64,458
North Macedonia 466 22.4 10,213
Kuwait 438 10.6 64,379
Azerbaijan 423 4.3 30,446
El Salvador 408 6.4 15,035
Oman 393 8.1 77,058
Cameroon 391 1.6 17,110
Czech Republic 373 3.5 15,516
Bulgaria 347 4.9 10,621
United Arab Emirates 345 3.6 59,177
Finland 329 6.0 7,398
Morocco 316 0.9 20,887
South Korea 300 0.6 14,203
Bosnia and Herzegovina 294 8.8 10,498
Kenya 285 0.6 17,975
Norway 255 4.8 9,132
Ethiopia 228 0.2 14,547
DR Congo 208 0.2 8,844
Greece 202 1.9 4,227
Senegal 194 1.2 9,764
Kosovo 185 10.0 7,413
Ghana 168 0.6 33,624
Australia 167 0.7 15,304
Qatar 165 5.9 109,597
Haiti 158 1.4 7,340
Mauritania 156 3.5 6,208
Venezuela 146 0.5 15,988
Albania 144 5.0 4,880
Bahrain 141 9.0 39,482
Zambia 140 0.8 4,552
Croatia 139 3.3 4,881
Malaysia 124 0.4 8,904
Mali 124 0.6 2,513
Uzbekistan 122 0.4 21,506
Slovenia 116 5.6 2,087
Costa Rica 115 2.3 15,841
Luxembourg 112 18.5 6,321
Nicaragua 108 1.7 3,439
Malawi 103 0.6 3,709
Ivory Coast 96 0.4 15,655
Somalia 93 0.6 3,196
Madagascar 91 0.3 9,690
Cuba 87 0.8 2,532
Lithuania 80 2.9 2,019
Palestinian Territories 78 1.6 10,621
Chad 75 0.5 922
Liberia 72 1.5 1,167
Estonia 69 5.2 2,034
Niger 69 0.3 1,132
Sierra Leone 66 0.9 1,783
Libya 64 1.0 2,827
Tajikistan 60 0.7 7,235
Central African Republic 59 1.3 4,599
Djibouti 58 6.0 5,059
Thailand 58 0.1 3,297
Congo 54 1.0 3,200
Burkina Faso 53 0.3 1,100
Andorra 52 67.5 907
Lebanon 51 0.7 3,882
Equatorial Guinea 51 3.9 3,071
Tunisia 50 0.4 1,455
Gabon 49 2.3 7,189
Nepal 48 0.2 18,752
Channel Islands 47 27.6 584
South Sudan 46 0.4 2,305
Guinea 45 0.4 7,055
Montenegro 45 7.2 2,893
Paraguay 43 0.6 4,548
French Guiana 42 14.8 7,514
San Marino 42 124.3 699
Angola 41 0.1 950
Syria 40 0.2 674
Mayotte 38 14.6 2,900
Zimbabwe 36 0.2 2,704
Benin 35 0.3 1,770
Uruguay 35 1.0 1,202
Eswatini 34 3.0 2,316
Latvia 31 1.6 1,220
Slovakia 28 0.5 2,181
Singapore 27 0.5 50,838
Guinea-Bissau 26 1.4 1,954
Suriname 24 4.2 1,483
Isle of Man 24 28.5 336
Cape Verde 22 4.0 2,328
New Zealand 22 0.5 1,557
Tanzania 21 0.0 509
Guyana 20 2.6 389
Cyprus 19 1.6 1,060
Togo 18 0.2 874
Georgia 16 0.4 1,145
Maldives 15 2.9 3,369
Martinique 15 4.0 269
Saint Martin 15 40.3 114
Sao Tome and Principe 14 6.6 865
Guadeloupe 14 3.5 203
Diamond Princess cruise ship 13 712
Lesotho 12 0.6 505
Sri Lanka 11 0.1 2,805
Mozambique 11 0.0 1,701
Jordan 11 0.1 1,176
Bahamas 11 2.9 382
Iceland 10 3.0 1,854
Jamaica 10 0.3 853
Mauritius 10 0.8 344
Malta 9 2.0 701
Bermuda 9 14.3 154
Namibia 8 0.3 1,843
Gambia 8 0.4 326
Trinidad and Tobago 8 0.6 148
Taiwan 7 0.0 467
Comoros 7 0.8 354
Barbados 7 2.4 110
Myanmar 6 0.0 350
Rwanda 5 0.0 1,879
Réunion 4 0.5 657
Monaco 4 10.3 116
Brunei 3 0.7 141
Aruba 3 2.8 119
Antigua and Barbuda 3 3.1 86
Uganda 2 0.0 1,128
Botswana 2 0.1 739
Turks and Caicos Islands 2 5.3 99
Belize 2 0.5 48
MS Zaandam cruise ship 2 9
Burundi 1 0.0 378
Cayman Islands 1 1.6 203
Liechtenstein 1 2.6 86
Curaçao 1 0.6 29
Montserrat 1 20.0 12
Western Sahara 1 0.2 10
British Virgin Islands 1 3.4 8
Vietnam 0 0.0 431
Mongolia 0 0.0 289
Eritrea 0 0.0 265
Cambodia 0 0.0 226
Faroe Islands 0 0.0 214
Gibraltar 0 0.0 185
Seychelles 0 0.0 114
Bhutan 0 0.0 99
French Polynesia 0 0.0 62
Papua New Guinea 0 0.0 62
St Vincent and the Grenadines 0 0.0 52
Fiji 0 0.0 27
Saint Lucia 0 0.0 24
Timor-Leste 0 0.0 24
Grenada 0 0.0 23
New Caledonia 0 0.0 22
Laos 0 0.0 20
Dominica 0 0.0 18
Saint Kitts and Nevis 0 0.0 17
Greenland 0 0.0 14
Falkland Islands 0 0.0 13
Vatican 0 0.0 12
Saint Barthelemy 0 0.0 7
Saint Pierre and Miquelon 0 0.0 4
Anguilla 0 0.0 3

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This information is regularly updated but may not reflect the latest totals for each country.

** The past data for new cases is a three day rolling average. Due to revisions in the number of cases, an average cannot be calculated for this date.

Source: Johns Hopkins University, national public health agencies and UN population data

Figures last updated: 28 July 2020, 13:40 BST

This appears to be an encouraging sign, but there are questions about the reliability of data in a region with relatively low levels of public health spending.

"Many deaths are not reported within the vital registration system and the causes of deaths are incorrectly classified," said Professor Kamran Siddiqi, a public health expert at the University of York.

But Dr Shahid Jameel says even if the deaths are under-reported, the difference from other areas of the world is "quite stark".

"The most plausible explanation is that the populations in South Asia are made up of far younger people than say in Europe and the US," Prof Siddiqi says.

Additional research by Waliur Rahman Miraj in Dhaka and Rama Parajuli in Kathmandu

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